The place for the tricyclic antidepressants in the treatment of depression

Objective: The new generation antidepressants have been an important advanc e in the treatment of depression. Since their introduction, their use has b ecome widespread and the role of the older tricyclic antidepressants (TCAs) has been suggested only as a second-line choice. This assumption is questi oned and the role of the TCAs as a first-line treatment for severe depressi on is discussed. Method: The relevant literature concerning the efficacy, tolerability and s afety of the antidepressant drugs is reviewed, particularly those studies w hich compare the newer antidepressant agents with the TCAs. Results: The newer agents are equally as efficient as the tricyclics in the treatment of mild to moderate depression. There are indications that the T CAs are more efficacious for severe depression. The tolerability of the dru gs appear about equivalent in terms of discontinuation rates; however, the side effects are different and clinicians need to be mindful of drug Intera ctions and the potential of the serotonin syndrome with the selective serot onin re-uptake inhibitors (SSRIs), problems not found with the TCAs. The TC As are potentially lethal in overdose; however, appropriate clinical manage ment appears to be a more important issue than the toxicity of the medicati on. Conclusions: The newer antidepressant agents are important advances in the treatment of depression. However, the TCAs still have an important place as the first-line treatment for patients with severe (melancholic/endogenous) depression.